CONFLCT OF NTEREST QUESTONNARE For vendor doing business with local governmental entity This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the vendor meets requirements under Section 176.006(a). By law this questionnaire must be filed with the records administrator of the local governmental entity not later than the 7th business day after the date the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code. A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a misdemeanor. FORM CQ OFFCE USE ONLY Date Received 1 Name of vendor who has a business relationship with local governmental entity. 2 3 Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.) Name of local government officer about whom the information in this section is being disclosed. Name of Officer This section (item 3 including subparts A, B, C, & D) must be completed for each officer with whom the vendor has an employment or other business relationship as defined by Section 176.001(1-a), Local Government Code. Attach additional pages to this Form CQ as necessary. A. s the local government officer named in this section receiving or likely to receive taxable income, other than investment income, from the vendor? Yes No B. s the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer named in this section AND the taxable income is not received from the local governmental entity? Yes No C. s the filer of this questionnaire employed by a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership interest of one percent or more? Yes No D. Describe each employment or business and family relationship with the local government officer named in this section. 4 Signature of vendor doing business with the governmental entity Date Adopted 8/7/2015
CONFLCT OF NTEREST OUESTONNARE For vendor doing business with local governmental entity Th s questionna re reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who has a business relationship as defined by Section 1 76.001 (1 -a) with a local governmental entity and the vendor meets requirements under Section 176.006(a). By law this questionnaire must be filed with the records adminisüator of the local governmental entity not laler than the 7lh business day after the date the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code. A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a misdemeanor. Date Received FORM CQ OFFCEUSEONLY 1l ruame of vendor who has a business relationship with local governmental entity. Lakeshore Learning Materials 4 f--l Check this box if you are f iling an update to a previously filed questionnaire. tl (The law requires that you file an updated completed queslionnaire with the appropriate filing authority not later than the 7th business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.) : 3l Name of local government officer about whom the information in this section is being disclosed. None ame of Officer This section (item 3 including subparts A, B, C, & D) must be completed for each officer with whom the vendor has an employment or other business relationship as defined by Section 176.001(1-a), Local Government Code. Attach additional pages to thìs Form CQ as necessary. A. ls the local government officer named in lhis section receiving or likely to receive taxable income, other than investment income, from the vendor? l--l v"' l-l ruo N/A B. ls the vendor receiving or likely to receive taxable income, other than inveslment income, from or at the direction of the local government officer named in this section AND the taxable income is not received from the local governmental entity? l--l v", ll l-_l ruo N/A C. ls the filer of this questionnaire employed by a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership interest of one percent or more? l--l v"' l-] No N/A i 1. i ì i i Ë D. Describe each employment or business and family relationship with the local government officer named in this section. N/A Signature of vendor doing business w th the governmental ent ty Adopted 81712015